Republic of the Philippines )

Camiling Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, ORLANDO VENTURA y GREGORIO, 53 years old, Filipino citizen, married, and
a resident of Barangay Birbira, Camiling, Tarlac, Philippines, after having been duly sworn
to in accordance with law, do hereby depose and state THAT:

1. On September 26, 2016, I pawned my necklace at the Cebuana Lhuillier,

Camiling,Tarlac and I was issued a pawn ticket which contained the following
entries, to wit:

Pawn Ticket : 21110SG024644

Loan Date : September 26, 2016
Maturity Date : October 27, 2016
Expiry Date : January 25, 2017

Principal Loan : P6,000.00

Item Description : Necklace Twisted Fake Lock
Grams : JI/3.9

2. After my transaction with the said pawnshop, I kept the said ticket inside my
wallet for safekeeping;

3. Today, when I was looking for the said ticket for the purpose of renewing my
pawn, I discovered that the same is missing inside my wallet. I tried to look for it
in my other wallets but I found nothing. I also asked the members of my
household if they have seen the same but all answered in the negative;

4. All my diligent efforts to locate the said ticket proved futile; hence, I now
consider the same as lost and beyond recovery;

5. I am executing this Affidavit to attest to the truth of the foregoing statements with
the intent of renewing the pawn covered by such ticket even in the absence of
the said ticket and for whatever legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24th day of

October, 2016 at Camiling, Tarlac, Philippines.

ORLANDO G. VENTURA
Affiant

SUBSCRIBED AND SWORN to before me on the date and place indicated above.
Affiant exhibited before me his Civilian Employee Identification Card with ID Number G14-
C-15232 issued by the AFP General Headquarters, Camp Gen. E. Aguinaldo, Quezon
City, valid until January 29, 2017.

Doc. No.:______; Page No.:______; Book No.:______; Series of 2016.